Following a palliative surgical treatment, doctors referred a 72-year-old Japanese woman due to prominent bone regeneration. She complained of purulent discharge from the left submandibular fistula and severe pain in addition to hypoesthesia in the left submental region. She was in severe pain with an impaired masticatory function, which disrupted her sleep pattern. Moreover, she had a history of severe osteoporosis because of renal osteodystrophy, for which she was receiving IV bisphosphonates.
The doctors did a panoramic radiograph at her first visit that showed a fracture in the left inferior mandibular border. However, there was minimal deviation. Moreover, computed tomography revealed a discontinuous left lower margin. It was extensive with a pathological fracture and had a morphologically irregular sequestrum formation.
After the CT results, the doctors made a diagnosis of stage III medication-related osteonecrosis of the jaw and a pathological mandibular fracture. To reduce the risk of intraoperative bleeding, the doctors replaced the dialysis anticoagulant from heparin to nafamostat mesylate right before the surgery.
The doctors did the sequestrectomy procedure under General Anesthesia and there were no postoperative complications. The intraoral and the submandibular fistula disappeared. Moreover, it was surprising for the doctors to observe that the prominent spontaneous bone regeneration disappeared six months after the procedure. Even though the 72-year-old had a severe systematic condition, the conservative surgical approach with sequestrectomy yielded desirable results. The patient had no symptoms for more than six years after the surgery.
Medication-Related Osteonecrosis of the Jaw
Medication-related osteonecrosis of the jaw is bone exposure that does not heal within 8 weeks. It can be probed through the intraoral and extraoral fistula in the maxillofacial region. Furthermore, it is prevalent in patients who have received a bone modifying agent with no history of head and neck radiation.
Bisphosphonates are frequently prescribed to patients with osteoporosis. However, medication-related osteonecrosis of the jaw can be a challenge to treat in elderly patients with co-morbidities. The cause is mainly bone-modifying agents, which also include bisphosphonates and angiogenic inhibitors. Moreover, getting a desirable treatment outcome is extremely difficult in patients with pathological fractures in association with extra-oral fistulae.
This rare case of spontaneous bone regeneration in an elderly Japanese woman is the oldest case of mandibular regeneration.
Reference: Yoshizawa, K., Moroi, A., Iguchi, R., Takayama, A., Goto, J., Takayama, Y., & Ueki, K. (2021). An unusual case of bone regeneration of a necrotic mandible with pathologic fracture in an elderly hemodialysis patient with medication-related osteonecrosis of the jaw: a case report and review of the literature. Journal of Medical Case Reports, 15(1), 1-7.